Complex regional pain syndrome (CRPS) is often associated with severe mental impairments. Initial pain-related fears in particular appear to be negative predictors for long-term therapy results. Procedures for cognitive behavioral therapy are an important component of treatment. The psychotherapy of CRPS consists of various elements that are implemented in the different phases of treatment. In the beginning the focus is on targeted psychoeducation. In the following activation phase body awareness exercises are accompanied by occupational and physiotherapeutic treatment in order to improve the perception of individual maximum loads. Behavioral analyses are used to uncover dysfunctional coping patterns, such as a fear avoidance coping strategy. In this case the use of graded activity treatment approach is indicated, in which the activity level is gradually increased. In the transfer phase psychotherapy supports affected patients in (re)designing their professional and private environments.

Das komplexe regionale Schmerzsyndrom (CRPS) geht häufig mit ausgeprägten psychischen Beeinträchtigungen einher. Insbesondere initiale Ängste scheinen negative Prädiktoren für die langfristigen Therapieergebnisse zu sein. Verfahren der kognitiven Verhaltenstherapie sind ein wichtiger Teil der Behandlung. Die CRPS-Psychotherapie besteht aus verschiedenen Elementen in verschiedenen Behandlungsphasen. Zu Beginn liegt der Schwerpunkt auf der gezielten Psychoedukation. In der folgenden Aktivierungsphase werden zur Verbesserung der Wahrnehmung der Belastungsgrenzen die ergo- und physiotherapeutischen Behandlungen durch Körperwahrnehmungsübungen begleitet. Verhaltensanalysen dienen der Aufdeckung dysfunktionaler Bewältigungsmuster, wie eines ängstlich-vermeidenden Stils. Dann ist beispielsweise ein Graded-activity-Behandlungsansatz indiziert, bei dem das Aktivitätsniveau stufenweise gesteigert wird. In der Transferphase unterstützt die Psychotherapie die Betroffenen in der (Neu‑)Gestaltung ihres beruflichen und privaten Umfelds.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A systematic search of the literature for systematic reviews of randomized, controlled studies on psychological and psychotherapeutic procedures from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.Cognitive behavioral therapies received a strong recommendation but biofeedback, guided imagery and hypnosis received a weak recommendation.

The efficacy of Eye Movement Desensitization and Reprocessing (EMDR) has been demonstrated for posttraumatic stress disorder. Despite promising research, it is still not clear if EMDR is a similarly effective treatment for chronic pain. Controlled trials are lacking and whether specific mechanisms underlie the effects remains unknown. The treatment of chronic pain aims at a reduction of subjective pain sensations. To achieve this goal without the usage of pain medications, i.e. through psychotherapy, is desirable for many reasons (e.g. reduction of treatment costs and side effects). Whether or not EMDR is an effective intervention for all chronic pain patients (or just a specific subgroup) constitutes an important question for psychological pain research.

Die Wirksamkeit von „eye movement desensitization and reprocessing“ (EMDR) ist für die posttraumatische Belastungsstörung klar belegt. Inwieweit dies auch für den Einsatz bei chronischen Schmerzen gilt, ist trotz vielversprechender Veröffentlichungen bisher unklar, da es an kontrollierten Studien mangelt. Auch die Frage, ob spezifische Wirkmechanismen für die Effekte verantwortlich sind, ist ungeklärt. Die Reduktion des subjektiven Schmerzempfindens ist erklärtes Ziel schmerztherapeutischer Behandlung. Dieses durch nichtmedikamentöse Verfahren, speziell auch durch psychotherapeutische Interventionen, zu erreichen, ist aus einer Reihe von Gründen (z. B. Reduktion von Kosten und unerwünschten Medikamentenwirkungen) erstrebenswert. Ob EMDR hier eine wirksame Intervention ist und bei welchen Schmerzpatienten die Methode wirkt, ist eine wichtige Fragestellung für die schmerzpsychologische Forschung.

Zusammenfassung Hintergrund Die planmäßige Aktualisierung der S3-Leitlinie „Fibromyalgiesyndrom“, AWMF-Registernummer 145/004, war für April 2017 geplant. Methodik Die Leitlinie wurde unter Koordination der Deutschen Schmerzgesellschaft von dreizehn Fachgesellschaften und zwei Patientenselbsthilfeorganisationen entwickelt. Acht Arbeitsgruppen mit insgesamt 42 Mitgliedern wurden ausgewogen in Bezug auf Geschlecht, medizinischen Versorgungsbereich, potenzielle Interessenkonflikte und hierarchische Position im medizinischen bzw. wissenschaftlichen System besetzt. Die Literaturrecherche nach systematischen Übersichtsarbeiten von randomisierten, kontrollierten Studien von psychologischen und psychotherapeutischen Verfahren erfolgte über die Datenbanken MEDLINE, PsycINFO, Scopus und Cochrane Library (von Dezember 2010 bis Mai 2016). Die Graduierung der Evidenzstärke erfolgte nach dem Schema des Oxford Centre for Evidence-Based Medicine, Version 2009. Die Formulierung und Graduierung der Empfehlungen erfolgte in einem mehrstufigen, formalisierten Konsensusverfahren. Wirksamkeit, Risiken, Patientenpräferenzen und Umsetzbarkeit von Therapieverfahren wurden gegeneinander abgewogen. Der Leitlinie wurde von den Vorständen der beteiligten Fachgesellschaften nach Überprüfung zugestimmt. Ergebnisse und Schlussfolgerung Kognitive Verhaltenstherapien erhielten eine starke, Biofeedback und geleitete Imagination/Hypnose eine schwache Empfehlung.

Die planmäßige Aktualisierung der S3-Leitlinie „Fibromyalgiesyndrom“, AWMF-Registernummer 145/004, war für April 2017 geplant.

This systematic review aimed at evaluating the efficacy, acceptability and safety of guided imagery/hypnosis (GI/H) in fibromyalgia. Cochrane Library, MEDLINE, PsycINFO and SCOPUS were screened through February 2016. Randomized controlled trials (RCTs) comparing GI/H with controls were analysed. Primary outcomes were 50% pain relief, 20% improvement of health-related quality of life, psychological distress, disability, acceptability and safety at end of therapy and 3-month follow-up. Effects were summarized by a random effects model using risk differences (RD) or standardized mean differences (SMD) with 95% confidence intervals (CI).Seven RCTs with 387 subjects were included into a comparison of GI/H versus controls. There was a clinically relevant benefitof GI/H compared to controls on 50% pain relief [RD 0.18 (95% CI 0.02, 0.35)] and psychological distress [SMD -0.40 (95% CI -0.70, -0.11)] at the end of therapy. Acceptability at the end of treatment for GI/H was not significantly different to the control. Two RCTs with 95 subjects were included in the comparison of hypnosis combined with cognitive behavioural therapy (CBT) versus CBT alone. Combined therapy was superior to CBT alone in reducing psychological distress at the end of therapy [SMD -0.50 (95% CI -0.91, -0.09)]. There were no statistically significant differences between combined therapy and CBT alone in other primary outcomes at the end of treatment and follow-up. No study reported on safety. GI/H hold promise in a multicomponent management of fibromyalgia.SignificanceWe provide a systematic review with meta-analysis on guided imagery and hypnosis for fibromyalgia. Current analyses endorse the efficacy and tolerability of guided imagery/hypnosis and of the combination of hypnosis with cognitive-behavioural therapy in reducing key symptoms of fibromyalgia.

Psychosoziale Faktoren spielen eine wesentliche Rolle in Prädisposition, Auslösung und Verlauf des Fibromyalgiesyndroms (FMS). Kognitive Verhaltenstherapien erhielten von der aktuellen deutschen, israelischen und kanadischen Leitlinie einen hohen Empfehlungsgrad für die Therapie des FMS.

Die Wirksamkeit und Sicherheit der Langzeittherapie mit Opioiden (≥ 6 Monate) bei chronischem nicht-tumorbedingtem Schmerz (CNTS) ist umstritten. Eine systematische Übersichtsarbeit mit Metaanalyse der Wirksamkeit, Verträglichkeit und Sicherheit in offenen Anschlussstudien randomisierter, kontrollierter Studien (RCT) wurde bisher nicht durchgeführt.

The efficacy and safety of long-term (a parts per thousand yenaEuro parts per thousand 6 months) opioid therapy (LtOT) in chronic noncancer pain (CNCP) is under debate. A systematic review with meta-analysis of the efficacy and harms of opioids in open-label extension studies of randomized controlled trials (RCTs) has not been conducted until now.We screened MEDLINE and clinicaltrials.gov (through to December 2013), as well as reference sections of systematic reviews of long-term RCTs of opioids in CNCP. We included open-label extension trials with a study duration a parts per thousand yenaEuro parts per thousand 26 weeks of RCTs of a parts per thousand yenaEuro parts per thousand 2 weeks duration. Using a random effects model, pooled estimates of event rates for categorical data and standardized mean differences (SMD) for continuous variables were calculated.We included 11 open-label extension studies with 2445 participants with nociceptive (low back, osteoarthritis) and neuropathic (radicular, polyneuropathy) pain. Median study duration was 26 (range 26-108) weeks. Four studies tested oxycodone, two studies tramadol and buprenorphine; hydromorphone, morphine, oxymorphone and tapentadol were each tested in one study. Of the patients randomized at baseline, 28.5 % (95 % confidence interval, CI, 17.9-39.2 %) finished the open-label period; 53.5 % (95 % CI 38.1-68.2 %) of patients entering the open-label period finished the open-label period. In sum, the total loss was 71.5 % (95 % CI 60.9-83.1 %) of all patients primarily included into the RCT. A total of 4.9 % (95 % CI 2.9-8.2 %) of patients dropped out due lack of efficacy; 16.8 % (95 % CI 11.0-24.8 %) dropped out to due adverse events (AE) in the open-label period and 0.08 % (95 % CI 0.001-0.05 %) of patients died during the open-label period. Only one study systematically assessed aberrant drug behavior of the patients: 5.7 % (95 % CI 3.4-9.6 %) showed aberrant drug behavior in the opinion of the investigators and 2.6 % (95 % CI 1.2-5.8 %) were judged to show aberrant drug behavior by independent expert assessment. There was no significant change (p = 0.50) in pain intensity between the end of the randomized period and the end of open-label phase (SMD 0.19 [-aEuro parts per thousand 0.03, 0.41]; six studies with 1360 participants).Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. LtOT can be considered in carefully selected and monitored CNCP patients who experience clinically meaningful pain reduction with at least tolerable AE in short-term opioid therapy.The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").

On p. 7, right column, the sentence "The mean average reductions in pain and disability were maintained from the end of the double-blind to the end of the open-label period up to 3 years later" is not correct. It should read "2 years" instead of "3 years".

Opioide sind wesentlicher Teil der Schmerztherapie von Tumorpatienten. Aber auch in dieser Patientengruppe kann eine Fehldosierung lebensbedrohliche zentralnervöse Nebenwirkungen und eine opioidinduzierte Hyperalgesie auslösen, weil das besondere Risiko besteht, dass diese Symptome nicht als Nebenwirkungen sondern als Folge der Tumorprogression fehlgedeutet werden können. Vorgestellt wird ein Patient mit Pankreaskarzinom 2 Jahre nach Pankreasresektion mit stärksten viszeralen Schmerzen und deliranten Symptomen unter hoher transdermaler und endonasaler Fentanyl-Dosis. Nach Entzug war der Patient psychisch unauffällig und konnte einer kurativen Operation (Resektionen von Narbenhernien) zugeführt werden. Er ist seitdem schmerzfrei (> 16 Monate). Der Fallbericht unterstreicht erneut die Notwendigkeit einer adäquaten Diagnostik auch bei scheinbar unbehandelbaren Verläufen und die Gefahr einer nur symptomorientierten Schmerztherapie bei Patienten mit Tumorleiden.

Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.

BACKGROUND:The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS:The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION:Meditative movement therapies (qi gong, tai chi, yoga) are strongly recommended. Acupuncture can be considered. Mindfulness-based stress reduction as monotherapy and dance therapy as monotherapy are not recommended. Homeopathy is not recommended. In a minority vote, homeopathy was rated as "can be considered". Nutritional supplements and reiki are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").